Inspection on 03/10/07 for Oakhaven - City of York Council

This inspection was carried out on 3rd October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Oakhaven - City of York Council 05/10/06

Oakhaven - City of York Council 18/01/06

Oakhaven - City of York Council 05/07/05

Oakhaven - City of York Council 23/11/04

Oakhaven - City of York Council 27/08/04

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Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Oakhaven - City of York Council 144 Acomb Road York North Yorkshire YO24 4HA Lead Inspector Jo Bell Key Unannounced Inspection 09:30 3rd October 2007 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakhaven - City of York Council Address 144 Acomb Road York North Yorkshire YO24 4HA Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01904 791599 01904 784 985 www.york.gov.uk City of York Council vacant post Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 2006 Brief Description of the Service: Oakhaven is a care home run by City of York Council and is registered to provide a service for 27 older people of either gender aged over 65 years who do not have any specialist requirements. Oakhaven was purpose-built approximately 50 years ago and is located within a short walk of Acomb Village centre. The accommodation is provided in single rooms on two floors. The upper floor is accessible via passenger lift. Structural alterations have been completed to create more open lounge space and additional toilets. Up to 6 day care places per day are available. The scale of charges per week are £432.42. Additional charges are made for toiletries, hairdressing and chiropody. Information regarding the service is available in the statement of purpose and in the previous inspection reports. Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key inspection of the service took place on Wednesday 3rd October 2007. Prior to the visit an annual quality assurance assessment was completed and surveys were sent out to a range of people. Eighteen surveys were returned in total, four each from service users, relatives and healthcare professionals. Five from staff and one from a care manager. One inspector spent seven hours at the service, during this time people using the service, their relatives and some staff were spoken with. The manager was available throughout the day along with care leaders to assist when needed. Documentation relating to care plans, risk assessments, complaints and health and safety were inspected and discussed. People discussed the service they receive, the activities and the meals provided. Issues regarding staff and the progress the service has made in the past 12 months was discussed with the manager. Since the last inspection the service has progressed well in a range of areas. The permanent manager has been in post for 8 months and has addressed the previous requirements and recommendations. This has had a positive effect on the care that people and their relatives receive. What the service does well: What has improved since the last inspection? The home have a permanent manager which helps to ensure consistency in the approach and the care people receive. The choice of food offered is in the process of being reviewed this will ensure that people air their views regarding the quality of food served. Stock balances of medication take place this helps to identify any errors. The home have started to undertake nutritional assessments, this helps to identify nutritional needs are being met. Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 6 People are protected from harm through robust safeguarding procedures, these include further staff training. People are cared for by staff who are effectively recruited and trained. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 is not applicable). People who use the service experience adequate quality outcomes in this area. Whilst people are assessed, they are not formally recorded. This may lead to uncertainty regarding whether needs can be met. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The pre-admission assessment which takes place was discussed with the manager and related to three people. Prior to a person entering the home the care manager completes a health and personal care assessment, this is very detailed and covers a range of areas. This is forwarded to the home. The manager also visits the person either in their own home, hospital or encourages them to have a trial visit at the service prior to becoming permanent. This assessment is not recorded, and whilst the manager can clarify with the person whether the home is able to meet these needs there is Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 9 no evidence to view which other staff can relate to. A review of this does take place after six weeks which people confirmed. Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. People who use the service experience good quality outcomes in this area. People have their health and personal care needs met. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: People are cared for by staff who are able to meet personal care needs. People spoken with all said they were well cared for. Surveys filled in confirmed that needs are met, and people are happy with the care provided. Three care plans were inspected and these contained assessments from when the person has entered the home, individual risk assessments and specific care needs. Plans of care set out the needs each person has and the care leader and key worker implement and deliver the care. Risk assessments are being introduced regarding nutrition, staff are in the process of completing these. A clear understanding is needed on how staff determine if a person is underweight. This will help clarify the rest of the process. Moving and handling assessments are in place though evidence is needed that these are regularly updated. The care plans are reviewed and evaluated though Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 11 currently it is unclear as to which part of the care plan this includes. Each person has a daily contact sheet, this is not consistently completed which means that it is unclear as to when certain personal care has been delivered. One care leader stated someone had developed a sore area a few days ago, there was no record of this in the notes. One person said “I would like some assistance on a morning but I am not always asked”, it was unclear in the records what personal care had been offered. Whilst these issues need addressing, the home has made good progress in this area and staff have a greater understanding of how to complete care plans effectively. People have access to the doctor, dentist and chiropodist. One doctor was visiting at the time of the inspection and evidence of visits by the district nurse and community mental health was available. The home is aware of how to report accidents or injuries through the Regulation 37 route. Privacy and dignity was maintained in the home, this was observed and discussed with people using the service and their relatives. Staff spoke in a pleasant voice and had a good rapport with people. The medication system was inspected. People have their medication administered in a safe and robust manner. Care leaders have attended medication training and are aware of how to administer, store and dispose of standard medication and controlled drugs. Three medication charts were inspected, these were satisfactory, on occasions the incorrect code had been written i.e. when no tablets had been supplied the code for refused was used. Staff also need to ensure medication is reviewed for example paracetamol, lactulose or medication that has not been used for over a month. The home is aware of how to record warfarin and adjust the dose accordingly. Stock balances of medication take place, and medication including eye drops and insulin are stored and recorded correctly. The home has progressed well in this area which helps to protect people from errors occurring affecting which could affect their well-being. Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. People who use the service experience adequate quality outcomes in this area. Whilst some activities are offered, religious needs are not routinely considered, though the food and drink available is satisfactory. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: People spoken to had mixed views regarding the activities provided. Some people said there were entertainers available, in house activities, card making, bingo, dancing and music evenings. One lady said “I had a lovely time dancing”, another person was happy watching the television and socialising with other residents. Activities are recorded in an activity book and each days events are written on the notice board. One person said they would like to go out more, another said she likes chatting to staff. Currently there are not enough staff available to have many one to one sessions, or take people out on trips. The home sometimes has to rely on relatives to take people out. Autonomy and choice is offered, religious needs are documented and whilst a few people confirmed that these needs were catered for, a discussion Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 13 regarding how these needs can be met is not always offered. People are able to get up and go to bed when they want, although one person did state that staff do not ask her if she wants any help on a morning because she is seen as independent. Visitors are welcomed into the home at anytime, this was evident when reading the visitors book and speaking to people. The lunchtime meal was observed. Currently a three month trial is taking place regarding the meals offered. This will identify if people prefer food cooked and served on the premises, or hospital food, which is currently served. People using the service and staff felt that food cooked on the premises would be preferable. However, the food at lunchtime looked appetising and the home has different small dining areas which are all pleasant and nicely decorated. Staff were aware of how to assist people in a dignified manner, different portion sizes were available and a choice of main courses was offered. Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. People who use the service experience good quality outcomes in this area. . People are able to voice their concerns through an effective complaints procedure and they are protected from harm. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The home uses the local authorities complaints procedure, the manager is aware of how this procedure works. One complaint has been identified which the manager has effectively addressed. One comment was “I have nothing to complain about”, another was “everything is fine, I have no complaints”. People spoken to were aware of how to make a complaint, which was echoed in the surveys from relatives and people using the service. People felt confident that the manager of the home would deal with any concerns. Since the last inspection care leaders have received training in safeguarding adults (adult protection), which has improved their knowledge and understanding of abuse. This was evident when speaking to care leaders and care staff. People in the home said they felt safe and protected. The manager is aware of the local authorities vulnerable adults procedure and is clear about the action to take if an abuse has been reported to her. Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. People who use the service experience good quality outcomes in this area. People live in a clean and well maintained home. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: People live in a pleasant environment. The home is purpose built and is located in the centre of Acomb (close to York) near many shops. The home provides people with a range of communal areas for socialising and dining. There are sufficient bathing and toilet facilities and people were observed knowing where these were located. All areas except one bedroom had a pleasant smell, general assistants are responsible for the cleanliness of the home. Staff have undertaken infection control training though the manager needs to identify how often this needs to take place as those staff who have worked at the home for a long time have not had training updates in this area. Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 16 People confirmed that the key worker ensures that personal washing and ironing is returned to their room. On a weekend care staff are expected to complete washing and ironing (there is only one general assistant on duty). There are sufficient washing machines and tumble driers for the amount of people living in the home. Staff are aware of how to ensure infection control procedures are in place. Protective clothing is available and worn as necessary. People confirmed they feel safe and comfortable in their environment. Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. People who use the service experience adequate quality outcomes in this area. People are not cared for by consistently sufficient staff. This means that some needs are not being met, although staff are competent and recruited effectively. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The home can cater for twenty seven residents and up to six day care people. There are not consistently enough staff to meet everybody’s needs. The manager is supernumerary and a care leader is always on duty, though they are often involved in writing care plans, completing risk assessments, auditing systems, administering medication, liaising with GPs/nurses, speaking to relatives and ensuring the shift is running smoothly. On some mornings there are two care staff and two general assistants. During some afternoon there is one carer on duty. This is not enough. At the weekend the general assistants are reduced to one, and the manager is not on duty. Some people are put at risk if the carer, and care leader are dealing with one resident, because there are up to thirty two other people who may need attention. The duty rotas also confirmed this. Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 18 This was highlighted at the last inspection twelve months ago and needs to be addressed. This contributed to low staff morale and people not feeling valued. People spoken to felt the staff did a good job but realised that this would be improved with more staff, this was also echoed in the surveys returned. Some staff have completed an NVQ level 2 or 3 in care and the home is keen to ensure all staff are working at the same basic level. The home has a twelve week induction programme which includes mandatory training, this was confirmed when speaking to staff and checking training records. This is a big improvement for the home and the manager has worked hard to ensure people receive adequate support through training and supervision. The recruitment procedure in the home was inspected. The manager is aware that two written references are needed along with a police and vulnerable adults check. Three files were checked and these had details of the application form and references. The police check could be evidenced and whilst the protection of vulnerable adults check had taken place this was not recorded anywhere because the police check automatically incorporates this. It would be beneficial having this evidence available. Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. People who use the service experience good quality outcomes in this area. The home is run in the best interests of the people using the service, though the quality assurance system needs improving. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The manager is experienced in caring for older people having previously been a deputy manager in another City of York Council service. She has completed her NVQ level 4 in management and is in the process of completing NVQ Level 4 in care. The manager is aware that she needs to apply to CSCI to become the registered manager of Oakhaven and has obtained the relevant application forms. The manager is open and approachable and has made improvements Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 20 to the home in the past eight months since she took over as the manager. She clearly runs the home in the best interests of the people living there. Currently there is no robust quality assurance system in place, a clear system for seeking views and opinions regarding the service needs to be introduced, this is part of the annual development plan which includes auditing of systems and evidencing how the service meets individual needs. Some of the care plans are audited, and the finances will be audited shortly. A residents meeting has recently taken place and regular staff meetings occur. People must be able to voice their views and opinions and appropriate action needs to be taken to address any outstanding issues, this will help the service progress. People’s finances were discussed and three wallets were inspected. Records were maintained and people can access their money for toiletries, hairdressing chiropody or other sundries. Three people confirmed this to be the case. No concerns were raised in this area. Health and safety was discussed and information in the annual quality assurance system included details regarding checks made to electrical equipment, emergency call bells and safety systems. The home is well maintained with water temperatures being recorded monthly. These were checked and were found to be within the expected range. The home has a fire risk assessment which will be updated shortly. A weekly fire alarm test takes place and staff receive fire training every year. A fire safety check had been undertaken in the past two months. Records confirmed this. There is a qualified first aider on duty, and staff complete moving and handling training and food hygiene on a regular basis. Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 1 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Individual care plans must be reviewed effectively to include updates of risk assessments. Clear evidence of the care given must be available to ensure all needs have been addressed. The home must provide enough care staff on a weekend and during the week when there are insufficient on duty to meet people’s needs. People must be able to formalise their views and opinions through the home’s quality assurance system. Timescale for action 03/11/07 2. OP27 18 03/11/07 3. OP33 24 03/12/07 Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations Peoples religious needs should be discussed and considered. Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Oakhaven - City of York Council DS0000034921.V333723.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!